Gait training and walking recovery after SCI

PROM UE

need to be WNL, esp shoulder extension

scapula needs to move

LEs PROM needed

-hip: 0-10 ext and full flexion

-HS length: 0-110 for KAFO or reciprocating gait orthosis (RGO) users

-knee: full extension

-ankle: 0-10 DF

-needed to attain “para-stance”

in para stance position

-GRF needs to be posterior of hip for the hip extension moment

With sufficient ankle DF, hip extension, & lumbar extension PROM, pt leans into anterior hip’s Y ligaments for stability.

for fxnal gait, pt needs to have 5/5 throughout UEs

-scapulae must be stable and mms strong

-for traditional “para-gait”

-50 dip rule

true MMT will help with bracing specifications

-do not rely on ASIS alone

—all mms need to be tested

-particularly important for pts with AIS C & D

other MSK considerations

• Lumbar flexibility to achieve para-stance

• Leg length discrepancy

• Scoliosis

• Orthopedic fixation

• Body shape/size

• Length of time since onset of injury

  • May require osteoporosis screening (DEXA scan) if its been 4-6 months since WBing

sensory considerations

-body awareness

—including proprioception/kinesthesia

-p!

-light touch

-deep pressure

-need more than AIS testing

—for where you need to perform skin checks, harnesses

interdisciplinary team assesses spasticity

caused by upper motor neuron lesion

interfere w mobility/standing/ambulating

spasticity PROS

-maintain mm bulk

-circulatory fxn

-postural control

-prevent weight gain

-may be indicative of recovery potential

spasticity CONS

PROM changes

interfere w orthosis use

-cause areas of increased pressure

-donning

other examinations for standing or gait

-BP for upright tolerance

-motivation: attendance; compliance w self PROM, skin checks and protection, bowel/bladder management

-cost/funding sources

-balancing gait w other therapy goals: transfers, WC mob, bed mobility, etc

Shepherd Center SCI Program: Criteria for Long Leg Bracing Program

Patient has desire to ambulate with specific and realistic goals

Patient within 10% of ideal body weight

PROM within following limits:Hip Ext (5 degrees), Knee Flex/Ext (WNL), Ankle DF (5 degrees), Passive SLR (110 degrees)

Skin intact

Stable cardiovascular and pulmonary systems (MD cleared)

Patient must be able to stand in parallel bars for 60 min with stable BP/joints

T12 and below (higher considered if all other criteria met)

50 body-weight dips

PT session compliance, must complete PT training before KAFO prescription

Independence with all transfers/WC mobility

WC propulsion: 1 mile in less than 20 min

Patients L2 and higher must be >6 months post-injury

Caregiver identified for assistance and training

SCIM III (like FIM)

-power wc → manual wc → dependent walking → independent walking

WISCI-II (like 10mWT)

1. Area of assessment

   1. Functional mobility & gait

   2. Amount of physical assistance needed as well as devices required 

can tell insurance that they are progressing

functional scale

SCI-FAI

assesses functional wlaking ability i amb individuals with SCI

-qualitative data

-participation

evaluation: cardiopulmonary comorbities

autonomic dysreflexia

take vital signs

hypertension/hypotension

smoking

DM, hypoglycemic

CAD

evaluation: integumentary

putting my eyes on them

so you can figure out what might have caused it

evaluation: cognitive and psychological

-TBI, concussion

-anxiety and depression, sleep and wake cycles, fatigue, motivation

PT diagnosis

-neuro classification (ASIA)

-force production

-fractionnated movement

Prognosis: predict potential recovery based on exam dat, evidence, and clinical judgment

Complete vs incomplete 

Predict optimal level of improvement in function

1. Paralyzed Veterans of America (PVA) Guidelines for Expected Outcomes based on level of injury

2. ASIA Impairment Scale

3. Somers textbook

ASIA A progniosis

3% ambulate

ASIA B prognosis

50 ambulate

ASIA C prognosis

75 ambulate

ASIA D prognosis

95%

canadian calculator for ambulation prognosis

L3 myotome, S1 dermatome, age at injury

POC: determine which intervention route or routes you will use, consider risks and benefits

Compensatory movement patterns

Recovery of normal movement patterns

1. Risks

   1. Fracture: proximal femur and tibia

2. Overuse: UE/LE; Especially consider shoulders and CTS with para-gait

3. Cost/benefit ratio of energy expenditure

4. Consider the benefits: Psychological; Physiological

standing/walking functional level

standing only; walking for exercise; functional amb (household and community)

equipment

Assistive devices

Orthoses

Electrical stimulation

Robotics

-lokomat

-rewalk

-EKSO

recommendations/referrals

-medical intervention: spasticity, surgery

-continuum of care

AIS A C1-C8

inadequate voluntary motor function for functional ambulation

PVA guidelines state that standing/ambulation require total assist

AIS A T1-T12

varying trunk and pelvic control

abdominals lowest functioning mm group

sensory deficits

HKAFO/RGO for children & some adults for exercise/household ambulation with assistive device 

Supervision-Min assist(T1-T8) or mod indep (T9-T12) with KAFOs for exercise/household ambulation with assistive device (walker or crutches)

T1-T8 modified independent in parallel bars

Difficulty with uneven surfaces

Wheelchair for functional mobility

AIS A L1

CAN HIP HIKE, CAN PROGRESS THE LIMB FORWARD

-pelvic control: QL

-sensory deficits

-KAFO: exercise/household amb w AD (crutches)

-WC: functional mob

AIS A L2

use less heads hip relationship

-hip control: iliopsoas

-sensory deficits

-KAFOs: functional household amb w AD (crutches)

-WC: functional mob

AIS A L3

-knee control: quads

-sensory deficits

-AFOs/KAFOs for household amb w potentional for functional comm amb w AD (usually ccrutches)

-may continue to use WC in community

AIS A L4-5

Knee and some foot control – anterior tibialis

Sensory deficits

RX: AFOs – Good potential for functional community ambulation with assistive device (crutches or cane)

incomplete injuries

-very complicated

-case by case basis

-level of injury (ASIA)

-AIS classification

-age, body habitus, resources, etc

techniques to gain PROM

-self or assisted PROm

-cruciate (crucifixion, open up chest) positioning for UEs

-mobs (talocrural mob)

-standing program

-serial/inhibitory casting

spasticity management

-watching HS, hip flexors, PFs

-oral meds

-neurolytic injections

-botox injections

-intrathecal baclofen pump trial/placement

theoretical benefits of standing

Maintain PROM/prevent contractures

Regulate bowel and bladder

Decrease spasticity/clonus

Improve strength (of what?)

Decrease risk of pressure sores

Increase circulation

Compensate for impaired autonomic response to position change (ie. BP issues – orthostatic hypotension)

Psychological/emotional benefits

Prevent or slow osteoporosis process* (remains controversial)

No evidence to support that static standing will promote return**

stall bars standing frame

working on trunk control

KAFO Pre-gait and functional training

-training braces (KLUNKERS)

-allows assessment of pt’s ability and training prior to ordering

-not customized

-difficult to control amount of DF

-heavy/ugly

other options besides KAFOs for lower SCIs

trial orthoses

ace wraps/theraband/taping

casting/bivalves

KAFO pre-gait and functional training: education and donning/doffing

•Re: overuse of shoulders for those without LE return

•Skin considerations

KAFO pre-gait and functional training: donning/doffing

•Short vs. long sitting

•Under (skin checks) vs. over clothing (no WRINKLES)

balance in “para-stance”

•Ankles dorsiflexed – fixed

•Knees extended

•Hips extended, leaning into Y ligament

•Lumbar extension

•Begin in the parallel bars with KAFOs

•Poor balance vs. orthotic modification

•Working within base of support and setting limits to allow patient with complete (para-stance) or incomplete SCI to recover balance

patients with complete SCI

push-ups, jack knife

pts with incomplete SCI

strengthening/forced use activities

all pts need to train these activities

-WC sit to/from stand practice

-WC frame and footrest type

Para-stance/Tripod position

•Drag to: Most inefficient, for weakest patients &/or early training

•Swing to

•Swing through: Fastest, requires most strength and guts

4-point vs. 2-point reciprocal

Most efficient per unit of time, but…

guarding the patient w complete SCI

Guard from back once up

•Prevention of accidental jack knife: hand at the back & on the shoulder 

guarding pt w incomplete SCI

Position self where needed for patient stability & best body mechanics

FALLING & FLOOR TO STAND

Remember to remove assistive device out of the way for patients with complete injuries Hamstring length

For patients with incomplete injuries, discuss gait assistive devices for safety vs. full potential

How to simplify the task? part-whole training

ramps

Remember toe clearance for all levels of injury & bracing levels when going up.

Remember that floor “drops” from beneath feet when descending.

Where will hips tend to “fall” when in orthoses with fixed ankle joints?

curbs and stairs

Direction for patients with B KAFOs

—Forwards method

—Backwards method: Descending backwards with a railing for fatigue & safety reasons

Other techniques for lower level and/or incomplete injuries

—Step over step

—Step-to method

Environmental constraints of curbs versus stairs?

—stairs: small space

ASSISTIVE DEVICES: practice with walkers and crutches

Parallel bars

Walker

Crutches

—Lofstrands vs axillary? 

Walking stick or NDT pole 

1 or 2 canes

Walker vs Lofstrand crutches

—Environmental constraints?

—Shoulder joint forces?

—Gait characteristics? 

more force through lofstrand or walker?

lofstrand

orthoses

1. An orthosis may not & probably won’t return the patient to prior functional level: Discuss expectations

2. An orthosis is a tool, like a cane or crutch, that they must learn how to use effectively

3. Never underestimate the importance of cosmesis.

4. Components: Remember that there are dozens of ankle & knee joints on the market. 

   The best joint to use may be the one with which your orthotist is familiar.

   Consider availability/expense (time, money) of orthotist & materials for maintenance & repairs.

5. Teamwork: Ask questions if the orthotist is more experienced OR learn together.

Few people post SCI continue to use their KAFOs long term

3 out of 40 continued to use (30 complete/10 incomplete injuries)

•Of those no longer using:38% - too time consuming to don/doff

22% - fear of falling

19% - impractical due to inability to use hands for other things

•Of those still using:Used max of 1x/week

•Of 10 patients issued standing frames, all 10 used at least 1x/month

paradigm shift in SCI rehab

Historically, the prevailing assumption has been that the CNS is incapable of repairing itself. 

Clinical decision-making has been guided by expected outcomes & the degree of motor/sensory loss demonstrated by a patient. Refer back to Scheets neuro class system, PT 6032. 

Compensation with braces & assistive devices, as well as teaching new movement strategies has been the gold standard for SCI rehabilitation.

BUT…Independent function does not equal recovery.

Activity based plasticity of neurons has been well known for more than 100 years

There is evidence that the spinal cord is capable of learning & controlling walking in animals with transected spinal cords.

Lovely et al (1986) Cats with transected cords demonstrated hind limb stepping in absence of supraspinal input

CPGs

Cats increased cadence & step length appropriately as treadmill speed was increased

•Possible interpretations: Spinal cord has a capacity to respond to afferent input (i.e. increased treadmill speed)

Hodgson, et al (1994)

Task specificity

Cats with completely transected cord

2 groups; Standing and Stepping

Each group learned the task for which it was trained, but could not perform the alternate task.

AIS A Human Studies

Human spinal cord interprets limb loading during stepping independent of supraspinal influence (EMG activity increases with higher limb loading).

Human spinal cord interprets velocity afferent input (EMG amplitude increases with faster stepping speeds), independent of supraspinal influence.

Subjects with “clinically complete” SCI can generate stepping patterns on treadmill, but cannot sustain it (3-10 steps).

The use of partial body weight support

Decreases biomechanical & equilibrium constraints.

Allows for repetitive practice of complex gait cycles.

But we have to be careful with how much we unload, as we know that loading increases EMG amplitudes, right?

BWST systems benefits

Provide earlier intervention to ↓ secondary complications

Provide task specific training, sensory input, and repetition

Minimize compensation

1. ↑ LE weight-bearing, ↓ UE weight-bearing

2. Promote good trunk, pelvic, and limb kinematics

3. Promote upright posture and balance 

   –20-40 min of cumulative stepping in 1-hr session

manual BWST training advantages

Fall-free environment

•Patient is more active, esp. at hips and trunk

•Allows for manual facilitation by trainer

•Allows for active arm swing

•Can use FES and/or orthotics

•Manual facilitation

manual BWST disadvantages

•Requires up to 3-4 trainers.

•Patients with severe spasticity can be very difficult

•Trainer fatigue and experience level (injuries) can alter results

•Inconsistent seating systems for the trainers

•Weight limit: 250 lbs

clinical considerations prior to locomotor training w BWST

1. Spinal stability

   1. Stabilization device used

   2. Clearance from ortho / neurosurgery

2. Weightbearing status

   1. Lower limbs

   2. Upper extremities

3. Joint PROM (ankylosis, fusion, casts)

4. Balance

5. comorbities

6. pain

7. CV status: metabolic demands, fatigue, ortho hypotension

8. pulm status: need for oxygenation, ventilation, suctioning; contra w rib fxs, pneumothorax

9. skin: contra w sacral or ischial wounds

10. urologic/GI: timing B&B, caution with indwelling catheters

11. MSK: some residual LE strength, spasticity, avoid musculo-tendinous injuries (i.e. sprains)

12. body habitus: weight limit is ~250 lb for most bWS systems and 297 lb for Lokomat.

CPG for improving walking

neuromodulation after SCI

1. Peripheral stim

   1. NMES/FES

   2. TENS

2. Spinal cord stim

   1. Epidural electrical stim (EES)

   2. Transcutaneous electrical spinal stim (TESS)

3. Brain stim

   1. Transcranial direct current stim (tDCS)

   2. Transcranial magnetic stim (TMS)

   3. DBS (deep brain stimulation?)